Dear Residents:

I introduce for our mutual learning a weblog on neurological education. The genesis of this is that in the course of your training, many issues arise that pertain not just to our treatment of an individual patient, but also to the process of becoming a neurologist and working within an increasingly complex health care system generally. I believe that our current methods of addressing these issues are inadequate: A personal conversation or email exchange doesn’t allow others to share in the learning. A blast email isn’t a good way to have a discussion––no one wants their inbox filled with dozens of “reply all” messages––and historically this has been reserved for rapid communication of policies and procedures. We do (and will continue to) discuss some of these matters in our morning report and other conferences, but time constraints make it difficult to do justice to complex issues in these venues.

It will be mutually educational to have a forum in which to explore in more depth matters of wider scope or interest: A recent (de–identified) acute stroke case might lead not only to a review of the guidelines on multi–modal brain imaging, but also a discussion of the associated resource allocation issues. A misdiagnosis of conversion disorder will raise questions about our approach to such patients and the rich history of hysteria. The development of templated H&Ps and discharge summaries in the electronic medical record raises questions about the proper balance of auto–population, cut & paste, and the dying art of narrative in our medical documentation. As some of you know, I’m a (very amateur) student of the psychology of decision–making and like to analyze our decisions, biases, and errors in this light.

To help maintain the educational focus, the blog posts will be categorized according to the relevant ACGME core competencies (Medical Knowledge, Patient Care, Professionalism, Communication and Interpersonal Skills, Practice–Based Learning and Improvement, and Systems–Based Practice). I may later add tags corresponding to the additional neurology–specific competencies that will arise as part of the ACGME’s Next Accreditation System (of which there will be about 36[!]).

My hope is that at least some posts will generate robust discussion in the comments. Please feel free to pose questions, suggest topics, or even submit your own posting––my plan is to address anything that has broad relevance in the blog rather than via email.

I’ll invite the rest of our faculty to participate as well, both by commenting and also guest–authoring their own posts. If this endeavor proves successful, it might be desirable to broaden the community to include other UW departments, other medical schools, or even the wider public. Rest assured that the posts will never contain protected health information, and I’ll omit any information that could be used to identify a specific physician unless authorization is provided. This also seems like a good time to note that anything written herein represents my own personal opinion and those of the other authors and commenters–not the UW, the VA, or any other employer.

The Ghost of Charcot

What’s the meaning of the blog’s title? The ghost of Charcot is a term that I learned from a residency colleague at the University of Virginia. It supposedly (I’ve never heard it since) refers to the phenomenon whereby the resident on call examines a patient and reports to the attending certain exam findings or usually the lack thereof. Overnight, the exam changes and when the attending makes rounds the next morning, there is now a Babinski sign or some other pertinent finding that you’re positive WAS NOT THERE the night before. The ghost of Charcot strikes again!

Kind Regards,

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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One Response to Introduction

  1. Talha says:

    Ghost of Charcot certainly has haunted my patients more than once. It is certainly more embarrassing than scary.

    I like to think of myself as a student of human decision making too. My biggest research tool is introspection – a tool fraught with biases and limitations. Inspection (of others’ decisions) may be a little better but still far from being objective. Fortunately, as a medical student I worked with a Neuro-physiologist at Cambridge (UK) who studied a decision we actually make several times a second – saccadic eye movements.

    Saccades are fascinating! We can make up to three per second and these are incredibly fast movements, up to 700 degrees/second. In our lifetimes, we will likely make saccades more times than our heart will beat! But what really determines where and when we make these movements. Roger Carpenter, my professor there had come up with a model of decision making called the ‘LATER’ model. LATER stands for (linear approach to threshold with ergodic rate). In simple terms it means that a decision is based on the cummulative data we gather from surroundings until we have enough data to reach a certain threshold where the decision is executed. But the rate of approach to threshold is not always the same despite the same data being presented on several different occurences; the rate (gradient) varies in a normal (Gaussian distribution). Where does this element of ‘randomness’ come from? Who introduces it? Why does it vary from one decision to the other? Science and empirical observation has not so far answered that question and I think, never will. 🙂

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